Sequestering Mental Health Care Is Insanity

Adam Lanza. James Holmes. Jared Lee Loughner. Seung-Hui Cho. These names instantly bring to mind some of the worst mass shooting massacres of the last decade or so. But they have something else in common. In addition to reviving calls for stronger gun control legislation, their heinous acts also turned America’s attention to dismal state of our mental health system. Every rumor and news report about the mental state of the mass-shooter-of-the-moment, was followed by demands to patch-up the “cracks” in our mental health system through which these young men supposedly fell.

Alas, support for improving mental health services have proven even more fleeting than support for gun control -- until the next shooting, that is. Unfortunately, the sequester will turn those existing “cracks” in to chasms, and create new ones.

The sequester does the most harm to the most vulnerable, and it’s hard to think of a more vulnerable population -- or one with fewer advocates, and less ability to self-advocate -- than the mentally ill; especially those with serious mental illness that require more care than our system currently provides. The sequester reserves some of its cruelest cuts for the mentally ill. (Of course, none of it has to happen. Congress passed the sequester, and Congress can repeal the sequester.)

These are just a few of the sequester’s consequences for our mental health, but they begin to paint a picture of what the sequester will do to many vulnerable Americans who will literally have nowhere to go, in a mental health system that was already stressed and under-funded before the sequester.

If you think these cuts are unlikely to affect you, think again. One in five Americans have some form of mental illness, and that 26.2 percent of Americans have a diagnosable mental illness in a given year. It’s entirely likely that someone you know --a coworker, a neighbor, a spouse or other family member -- is living with mental illness. Perhaps you are, too. And since 67 percent of adults and 80 percent of children who need mental health services don’t receive them, there’s a good chance that you or someone you know and love is living with untreated mental illness.

If you or someone you know is living with mental illness, and has tried to get help, you know how little help is available; especially if you happen to be poor and/or have a serious mental illness. America spends about $113 billion on mental health treatment, just 5.6 percent of our national budget. Most of that goes to prescription drugs and outpatient treatment. If medication and outpatient treatment doesn’t help, you’re pretty much out of luck unless you can get yourself arrested in the right state or county. Otherwise there’s nowhere for you to go.

Understanding how we got here requires a brief history lesson. But first , let’s have some fun. Try this. Head over to the internet search engine of your choice, and search for “abandoned mental hospitals.” In just 31 seconds, I got about 304,000 results. Check out a few links, and you might begin to think that the country is just littered with these huge, decaying buildings, quietly beckoning “urban explorers” to traipse their dark, dank halways. That’s because it is. There’s probably a crumbling monument to our former mental health infrastructure in your own community.

It would take more time or space than I have here to cover the history of mental institutions or psychiatric hospitals in America. They are the stuff of legend, and the source of old horror stories whispered about in communities, and sometimes widely reported in the news. (Not to mention television’s “American Horror Story” series.) Some were awful places where vulnerable patients were abused by untrained and/or uncaring staff. Some were places where people with serious, and sometimes little-understood, mental illnesses to go.

At the very least, for nearly a century there was somewhere for the seriously mentally ill. Then the trend towards “deinstitutionalization” -- which began in the mid 1960′s and culminated in 1981, when Ronald Reagan ended the federal government’s role in providing mental health services, cut federal mental health spending by 30 percent, and block-granted the rest to the state -- changed all that.

Time, right-wing obstructionism, and the recession did the rest, on the state level. Since 2008, about 31 states have cut mental health spending, and those cuts surpassed 10 percent of the mental health budget in one third of those states. In 2012 alone, states have cut more than $840 million in spending on mental health services, further burdening and already stressed system. Nine state run psychiatric hospitals were closed during this time, and another 3,200 beds for the mentally ill were eliminated in 29 states.

At the same time, states have experience an increase in demand for mental health services due to the recession. Half reported a rise in need for services, and 27 percent reported a rise in need for crisis services. Meanwhile, congressional Republican obstruction of efforts to increase aid to states only ratcheted up the budget pressure in the states.

The consequences for mental health workers and patients just increase stresses on the mental health system. Mental health professionals have seen their pay cut or their salaries frozen for years. People charged with assessing treatment needs and providing treatment have to resort to food stamps to keep food on their tables. (The sequester will take a chunk of that, too.)

For patients, it means access to mental health professionals is worse than access to other health professionals. Some 89.3 billion Americans live in federally designated “Mental Health Professional Shortage Areas,” compared to 55.3 million living in primary care shortage areas, and 44.6 million living in dental health shortage areas. Low income patients experienced longer waits for services, received less money and help to get housing and jobs, and spent more time in the emergency room.

Patients who don’t end up in the emergency room stand a good chance of ending up in the criminal justice system. Shortages of adequate care facilities has made prisons becoming the de-facto safety net for the mentally ill, and the best shot at getting care in some places. Nearly half, 45 percent of federal prison inmates have some form of mental illness, while 56 percent of state prisoners and 64 percent of local inmates suffer the same. Taxpayers end up supporting the incarceration of the mentally ill to the tune of $9 billion per year.

A 14-year-old with large brown eyes and tightly cropped hair told me a few weeks ago that voices were telling him to kill people. A day before the Sandy Hook school massacre, he threatened to light his house on fire and stab everyone in the family, according to his mother. This boy -- whom I'll call Trevor -- is a severe case, presenting the early, violent symptoms of schizophrenia at an age when the illness often begins to emerge. Untreated, his condition poses a serious danger to himself and those around him.

... Trevor's coverage provides for mental health care, but most psychiatrists in his area do not accept it because of the low reimbursement rates. Those offices that do have two- to three-month waiting lists. Trevor needs psychiatric care and cannot wait months to get it. Last October, when my concern about Trevor first began to escalate, I made a dozen calls and finally managed to get him in to see a psychiatrist near his home. The doctor, according to Trevor's mother, spent 15 minutes with the boy. He diagnosed Trevor with obsessive compulsive disorder, prescribed no medication and suggested that Trevor continue to see me weekly. From what I know of Trevor, 15 minutes is insufficient to gather the information necessary for a diagnosis.

Trevor's statements to me in December -- referred to as homicidal ideation -- demanded, both legally and ethically, that I send him to an emergency room. In North Carolina, as in many states, there aren't enough hospital beds to accommodate mentally ill individuals in crisis. Physical maladies and injuries take precedence, and those with mental-health issues often do not get out of a waiting room. Trevor spent five hours at the emergency room, then was sent home with instructions to call the hospital's adolescent mental health team the following day; his mother was unable to reach a member of that team when she called, she told me.

For mental health providers in North Carolina, 2013 marks another year of cuts to Medicaid reimbursement rates, which have declined steadily since 2008. States are responsible for a larger portion of mental health services than they are for physical services, which means mental health is hit hard by state budget negotiations. More than $4.3?billion has been slashed from state mental health budgets nationwide since 2009, according to the National Association of State Mental Health Program Directors. South Carolina, Alabama, Alaska, Illinois and Nevada are among the states that have had the deepest cuts.

This is the state of mental health care for people like “Trevor” before sequestration cuts to mental health services kick in. Ideally, Beckwith says, “Trevor” would be admitted to an inpatient facility for evaluation and monitoring. The reality is that he most likely won’t be. In many communities across the country, those places don’t exist anymore, and the few that do simply don’t have enough beds. The mental health services that do exist for “Trevor” are so far away that his family can barely afford gas money for weekly outpatient therapy visits, and so overtaxed to spare the time and attention “Trevor’s” condition requires.

“Where will all this leave Trevor?” Beckwith asks. Where will all of this plus the sequester leave “Trevor” and thousands like him across the country? And the sad part is that it doesn’t’ have to happen. Congress created the sequester, and Congress can just stop it.

The sequester is only going to make this worse for “Trevor” and thousands of others like him. We’ll never know anything about the vast majority of them. We’ll have no reason to know their names until another of them falls through the widening and multiplying “cracks” in our mental health care system, and becomes the latest staple in our 24-hour news cycle.

Then we’ll quickly forget them, and probably do nothing to stop the next one from falling through those unprepared “cracks.” That, if you ask me, is insane.

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